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Despite the slowing spread of COVID-19 in Hong Kong, the epidemic has put enormous pressure on the already strained healthcare system. While there is still risk of a resurging outbreak at the end of the year, vigilance and surveillance need to remain high. Nevertheless, looking on the bright side in these dark times, the epidemic has raised people’s health awareness. As primary healthcare (PHC) services emphasise on preventive care, particularly encourage people to manage their own health and receive necessary care in community, we believe developing an all-round preventive healthcare system is one of the ways out in the long run.
The Bauhinia Foundation Research Centre (the Centre) today released a study report of the ‘Moving towards universal health coverage: Overseas experiences on enhancing PHC’. As the name suggests, the study examined the experiences in developing PHC services in seven selected places (England, Australia, Singapore, Canada, the Netherlands, Israel and Mainland China). The Centre has made cross-references to their vision, policy directions and initiatives with a view to mapping out a service model that suits our society most. (See Appendix I)
The Centre’s Director Dr Donald Li, a family doctor (FD) and the Convenor of the study proclaimed, ‘In response to the outbreak of COVID-19, the Government in last Budget undertook to allocate sufficient resources to strengthen the healthcare system and provide support to anti-epidemic efforts. The commitment has aligned with the public expectations of the Government. To ensure the provision of comprehensive services and sustainability of the entire healthcare system, we should do our utmost to bring a paradigm shift in healthcare from hospital-based to community-based, and broaden the safety net for the entire population. By drawing reference to the experiences of the seven places in providing PHC services, we conducted in-depth analyses with a view to formulating a development blueprint for PHC services in Hong Kong.’
The Centre’s study 'Healthcare for All: Why and How?' published in last September examined the obstacles and challenges faced in developing PHC services in Hong Kong, the policy recommendations we made aimed at improving Hong Kong people’s health condition. In this latest study, we looked at experiences of the selected places in developing their PHC systems, in particular, the provision and delivery of PHC services, service quality, monitoring and supervision of services as well as health awareness of people. Basing on the 6-A assessment principles developed in the previous project and from the perspective of healthcare financing, we summarised our findings in the form of questions and answers.
Despite there being no one-size fit all answer to the key factors attributing to the development of PHC services, the experiences from the selected seven places indicated that government plays a vital role in promoting PHC services and its commitments are the key to success. All the seven governments have proactively reformed their PHC services and financing strategies with respect to their population health and economic conditions. The Centre has identified some good practices among the seven places which are summarised as follows (please refer to Appendix II for the summary of recommendations):
The healthcare coordination platforms in Australia, England and Singapore that emphasised on collaboration can serve as a service model in enhancing service efficiency. By means of service commissioning, England and Australia have distinguished the roles of ‘service provider’ and ‘service purchaser’ for healthcare teams. In terms of service provision, healthcare professionals will remain taking a dominant role. When it comes to service procurement, representatives from the regional government and the community as well as other PHC team members will proactively participate in coordination, planning, formulation, and budgeting. With a clear delineation between roles and the enhanced collaboration network, PHC services are capable of meeting healthcare needs of the community.
To ensure the provision of high-quality PHC services are delivered by general practitioners (GPs) continuously, the Australian Government has rewarded GPs to work with their local Primary Health Networks (PHNs) by offering them financial incentives. It also requires GPs to regularly provide clinical data on risk factors contributing to chronic diseases. The programme not only allows PHNs to provide feedback but also ensures continuous improvement of services. The directive principles of the programme are worth considering by the Hong Kong Government.
As FDs are the first contact point of individuals and families in a continuing healthcare process, it is important to ensure that an adequate number of doctors is in place to cope with quality service demand. In Canada, a sufficient amount of FDs is trained and many medical students are willing to practise in the specialty of Family Medicine. One of the reasons is that the postgraduate level of residency in Family Medicine takes only two years, much shorter than other specialties that take five to six years.
FDs focus on prevention and early identification of disease and act as coordinators for referral to specialists and hospital care. In England and Canada, patients will need a referred-consultation to specialists. It is noteworthy that in the Netherlands and Australia, the cost of care will not be covered by private insurance plan if residents visit specialists without a referral. Such practice encourages people to seek medical treatments from GPs or FDs, ensuring effective delivery of primary care functions and utilise the resources of PHC and specialty services. In Mainland China, signing of GP contract service is promoted through a referral gateway between community health centres and hospitals. Residents are encouraged to visit their signed GPs in the community when they start feeling sick, and they are given priority for care in the hospital with GPs’ referral. The pairing of GP and resident helps build a stable doctor-patient relationship in the community.
Connectivity is the key factor to integrate resources and promote cross-sectoral collaboration. Israel has taken some time to consolidate and materialise patients’ health record among hospitals and the community through the e-health record systems. The electronic systems share patients’ health records with all FDs, and allow a seamless interfacing between different healthcare providers, (e.g. doctors and hospitals). It not only helps bring down the cost of health monitoring, but also forms a basis for developing relevant PHC measurement indicators. In Hong Kong, the Electronic Health Record Sharing System (eHRSS) has yet gained popularity from members of the public and doctors. In 2016, two-thirds of 5,000 private clinics were not connected to eHRSS, such level of participation and usage rates were far from satisfactory. The Government is advised to adopt all-round measures to boost the participation rate and ultimately allow more service users to share the health records.
In England, the Care Quality Commission, an independent regulator has been set up to formulate statutory procedures, administrative and management arrangements as well as a system of quality assessment on PHC services. The Australian Government has set up health indicators and quality assurance framework to measure and monitor PHC services in different ways, in an attempt to assess the health level of residents. In Hong Kong, the Government has already established the Primary Healthcare Office to oversee and steer the development of PHC services at the bureau level, but all along lacks a long-term plan to establish a statutory PHC Authority to assess PHC services in a comprehensive manner.
To ensure the sustainability of the healthcare system, governments of different places have strived to contain the medical expenses at an affordable level amid the growing demand of healthcare services. Findings in our previous study revealed that despite growth in the overall PHC spending in recent years, the proportion of PHC expenditure (2016/17) in Hong Kong accounted for less than 15% of the total public healthcare spending. The Centre believed there are inevitably pros and cons in every single financing source; hence the notion of shared responsibility for health should be strongly advocated. The mixed model of ‘three pillars’ in Singapore emphasises the concept of collective responsibility. Its medical savings scheme under the Central Provident Fund requires both employers and employees to make mandatory contributions to the healthcare savings account, and allows the balance to cover dependents’ healthcare expenses. The Singaporean Government also provides tax incentives for those who make voluntary contributions. These relatively flexible arrangements have broadened the source of financing and instilled the idea of taking responsibility for one’s own health among Singaporeans.
The Centre’s Chairman Lau Ming-wai added, ‘A healthy living style, such as smoke-free, regular exercise, and balanced diet, is the best way to prevent diseases. Apart from disease prevention, mental health should not be neglected during epidemics. We notice that the Government has indicated to allocate sufficient resources for providing appropriate support to people with mental or emotional distress. The role of FDs, as a coordinator of the PHC service team, not only helps offer timely and accurate health precautions advice to reduce risk of outbreak, but also provides early intervention to people with initial signs of mental illness. In England, mental health therapy has already been integrated into their PHC services. The Hong Kong Government should consider expanding the scope of services of the District Health Centre (DHC) by adding mental health therapy, so as to provide a more comprehensive service to citizens.’
Dr Donald Li agreed to Chairman Lau’s view and reiterated, ‘PHC is the first line of defence against disease in the community, the Government should proactively promote a continuous, comprehensive and holistic care concept of FDs, so as to raise people’s health awareness and instil the idea of preventive healthcare. Along with the commencement of Kwai Tsing DHC, the Government should expediate the expansion of DHCs to every district in Hong Kong, so as to lay a solid foundation for PHC services in the community. The city’s PHC development is lagging behind, the Government should make extra efforts in promoting PHC and encouraging cross-sectoral collaboration among health professionals, enabling well-coordinated and high-quality PHC services to integrate into the community.’
More information about the study report is available at our thematic site (http://intlphc.bauhinia.org).